HospitalInspections.org

Based on interview and record review the facility failed to provide care in a safe setting when Patient #1 was not documented as a risk for intentional harm to self and placed on a high level of observation as the facility policy required and failed to document the rational for a lower level of care. (Patient #1)

Findings Include:

Review of the facility provided training tools for SUICIDE PREVENTION screening and assessment (undated) reflected, "... Suicide assessments should be conducted at first contact, with any subsequent suicidal behavior, increased ideation, or pertinent clinical change; for inpatients, prior to increasing privileges and at discharge.
RISK FACTORS
Suicidal behavior: history of prior suicide attempts ...
Current/past psychiatric disorders: Especially mood disorders, psychotic disorders...
Key symptoms: anhedonia, impulsivity, hopelessness... command hallucinations...
2. PROTECTIVE FACTORS
Protective factors, even if present, may not counteract significant acute risk...
HIGH
Psychiatric disorders with severe symptoms, or acute precipitating event; protective factors not relevant Potentially lethal suicide attempt... Interventions: Notify Physician, order for SI precautions, communicate with staff, 1:1 placed unless physician writes order for lower level of observation
5. DOCUMENT
Risk level and rational; treatment plan to address/reduce current risk ...Risk Level should show documentation to support that level of risk ..."

Review of Patient #1's History and Physical dated 11/15/18 reflected "This is a gentleman with known history of bipolar, depression and schizoaffective disorder admitted to Oceans with voicing suicidal attempt by cutting his left wrist. States he has had auditory hallucinations telling him to hurt himself and to hurt others...."

Review of Patient #1's Preadmission note dated 11/14/18 reflected, "Per intake staff; PT VOICED AH, HE STATED THAT THE VOICE TOLD HIM TO KILL HIMSELF, PT CUT HIS LEFT WRIST IN CROSS SHAPE REQUIRING 8 STITCHES IN AN ATTEMPT TO END HIS LIFE TO GET RID OF THE VOICES. Per MD: History as noted and verified with patient. Pt admits depression x 3 months, with SI, with past SA as noted above, with sleep and appetite ok, with AH of voice telling; him to kill self, and see VH of shadows on walls. Pt denies HI. Pt denies ETOH or illicit drugs."

Review of the Patient #1's Psychosocial Assessment and multi-treatment integration note (unsigned or dated) reflected, "... a 22 year old [sic] Hispanic male who present [sic] to Oceans on an EDO. Pt attempted SA cutting left wrist after voices commanded him to do so. Pt explained that he has A/VH of commanding voices.... He stated he is diagnosed with schizoid-affective disorder."

Review of Patient #1's Intake Screen dated 11/14/18 reflected "... Pt a danger to self as evidenced by SA by cutting Lt wrist and voices A/V Hallucination and has increased depression."

Review of the Admit Nursing Suicide Risk Level Screen dated 11/14/18 at 11:10 pm reflected the following:
Nurses Notes dated 11/18/18 at 10:55 pm reflected, "...Mood depressed.... Thought Content Hallucinations: Auditory Visual ...Denies SI, C/O Hallucination, (V) on occasions ..."
Nurses Notes dated 11/19/18 at 6:45 pm reflected, "...Mood Depressed, Agitated Behavior Isolative ... Thought Content, Hopeless ...Receptive to interventions ... Q 15 checks...."
Nurses Notes dated 11/20/18 at 6:45 pm reflected, "... Mood Depressed, Agitated... Behavior Isolative, Thought Content, Hopeless ..."

During an interview on the morning of 11/28/18 in the facility's administrative office, Staff #1, Director of Clinical Operations confirmed the Risk Assessment was not filled out correctly and Patient #1 was not placed on a 1:1 observation.